05 June 2007

Life in the (Animal) ER

JoVE mentioned a childrens' book about what I do in her post today. I don't know anything about the book, particularly, but I would suspect it's edited heavily for the child audience. I've been reading this book lately, and although its focus is human medicine, the intellectual and professional challenges it describes are very much my own.

My work certainly does have its interesting moments. Last week I saw both John Kerry and Jessica Lynch in the same night. Not the celebrities, just regular people with those names, but it still struck me as funny. And I see dogs and cats with porcupine quills, and skin infections, and broken toenails, and all sorts of other straightforward, routine sorts of cases that are an emergency clinic's bread and butter much the way vaccine appointments are for a day practice.

But a lot of what I do also makes people cry. We do an inordinate number of euthanasias. Sometimes people bring their pets in specifically for this reason. They've been watching their pet decline for some time and they have made the decision that the time has come to say goodbye. Many, however, don't realize that they are going to have to make this decision. They know that their pet is sick, but they don't realize just how sick. And I have to be the one to tell them. Or their pet dies in the hospital and I get to be the one to make that phone call.

After 13 years of doing this, I'd like to think that I'm actually pretty good at that part of the job. It is, for most of my clients, the loss of a family member - a major life event - and I try to be ever mindful of that fact and do what I can to make it just a little bit easier for them, as do all of our staff. Most people recognize that effort and appreciate it.

Sometimes, though, I have to deal with people who just don't get it.

I mentioned yesterday that I had one sort of frustrating case to deal with near the end of my shift. My senior tech triaged back a little toy poodle who was recumbent and too weak even to lift her head, her gums pale and dry from septic shock and dehydration and just the slightest bit jaundiced. When I put my hand on her, I realized that she had large areas of skin that were necrotizing - literally rotting on her body - with pockets of what I was pretty sure was pus underneath. I stuck a needle into one of the fluid pockets and got out a brown-grey fluid that looked and smelled like raw sewage. When I stained some of the fluid later to look at it under the microscope, I could identify at least three distinct populations of bacteria. This was a dog that was highly unlikely to survive.

As it happened, the dog had not received any veterinary care for several years, but it's questionable as to whether or not this had anything to do with the problem in the first place. It is possible that if they'd been more of a mindset to have the dog checked when she'd first acted sick two days previously that things might have gone differently. It is also possible that she had some underlying chronic disorder that had not been caught and had negatively impacted her immune function. At a fundamental level, though, what was going on with the dog was likely not directly due to any fault of the owners.

When I went into the exam room to talk to the owners, they turned out to be a leather couple who lived in town. The half of the couple who was the actual owner of the dog seemed quite nice and, I think, more or less grasped the situation. His boyfriend, however, needed to have the shit slapped out of him. Unfortunately, he was the one who was doing most of the talking for the pair.

I explained, as clearly as I could, what was going on with the dog and told them in no uncertain terms that the dog's only hope was aggressive treatment, and even then she only had the slimmest chance of survival. And even if, by some miracle, she managed to survive the immediate problem of infection, she was going to lose a lot of her skin, which would require skin grafts ideally or at the very least very long-term open wound management. The only viable options, I explained, were aggressive treatment for septic shock or euthanasia. The boyfriend responded in a thick Southern drawl, "We don't believe in that. That's murder. That Dr. Kevorkian should be in HAY-ull."

Say what? Usually, whenever I hear Southern, I have to ask where the person hails from. Earlier that day I had a client from Charlotte whose dog had come from South Carolina, about an hour from my hometown. With this particular guy, though, I just didn't want to know.

At first they wanted just to take the dog home on pain meds, where I told them that she would certainly die. That is, until I made them sign an AMA* form. The boyfriend balked at that, and then they wanted to know about admitting the dog. The initial estimate I had given them was simply not a financially viable option, so I had to rework the estimate, knowing as I did so and making it explicitly clear that it was a suboptimal approach. Still, we admitted the dog and I set about doing what little I could for her, knowing that it was an exercise in futility.

She died about a half hour after I'd left. I'm told the boyfriend complained that we were too expensive.

It's rough having to deal with folks like that. Good thing it is not too common. And it must be stressful having to deal with so many very sick animals, though I guess that is part of being an emergency clinic. I know I wouldn't take an animal to the vet at night if I thought it could wait until morning.

Dealing with death sensitively is such an important part of your practice. We had a tough call on euthanizing a cat once and our vet actually sent us a card about a week later saying it was a tough decision and that she thought we did the right thing. That was such a nice thing to do.

Do vets actually get much training in dealing with those issues though? Or is your training mostly focused on the science?

There's this small piece in me that wonders whether the poor thing waited two days b/c the boyfriend thought it was too expensive to bring her in when she could have been saved..At least she got to spend the last hours on pain meds in a safe place.poor thing

Ack, you poor guy! I'd imagine you see a lot of pets that don't get regular vet care. So, was it better that the little poodle was safe and on pain meds, or would it have been better for it to go home where people and things were at least familiar? Poor baby indeed! That bf sounds like a real ass! You should've recommended he do a cost benefit analysis of preventative and timely care vs waiting to the dire end.

Oh that poor dog! What she must have been suffering is beyond my ability to even imagine. I tend to think that we see the worst in people when they are under duress and that these were normally nice, kind people. And it isn't all that unusal to displace guilt onto the nearest target whether it is deserved or not. But, Mr. Boyfriend was out of line on many, many levels here.

You are a hero. As an pet owner and general friend to animals, I am so very glad that you are there to do the job and make the decisions that I could never make. I'll give you the, "thank you" that you didn't get yesterday.

It seems as though the "customer service" aspect of nearly every profession can be most difficult. Or as I like to say, "Other people ruin everything." I'm sorry about the pup. It never hurts to remind people that it is harder to get into vet school than medical school, and yet the pay doesn't reflect that. Not to mention seeing the heartbreaking things you do and having to deliver bad news to people who truly love their pets. Or having to deal with people who just don't have it together enough to do the right thing. I suspect your patients and their owners truly appreciate having such a kind and compassionate person at such awful times. I know I would.

I'm glad the dog died a far better death with you than with its clueless owners. It was not an exercise in futility. You gave that dog some comfort, and that is what counts.

Both times I was the one in the family who had to make the decision to euthanize a beloved cat. Nobody, not my husband nor my kids could bear to make that decision, even though they knew it was the right thing to do. I stayed with Buffy and with Milo as they were injected, watching the life fade from their eyes. Milo was the toughest, having lost my husband only five months earlier. And afterwards, my vet at the time, a wonderful woman, put her arms around me as I sobbed. But we had tried everything we could.

If it ever comes to that point with Cleo, my dopey but adorable cat, I hope I'll have the strength to make that decision again. But if you love them, you find it, somewhere.

I just started a job at an emergency vet clinic as a hospital assistant. I have one year of vet tech school left, and it amazes me the number of these type of people you meet on a daily basis. Very few people , it seems, think about health care for their pets before they adopt them. Many of the patients at our hospital could be treated if the owners had the funds, and others don't want to spend the money so it is easier to euthanise. The patients that there is no hope for are the ones that are forced to suffer for long periods because the owner isn't ready to let them go. The number of strays we get is also very sad- microchips are available and help lost pets get back home. What do think about machine washable knitted pet blankets in vet hospitals?

I would like to slap the shit out of them for you. I just don't get this at all. My friend's in-laws down the street has a dog that needs to be put down but they won't. I dog-sat him for a few days and seriously thought he was going to die while they were gone. It was horrible.

Christopher, I know the animal shelter nearest us will take any sort of machine washable, snuggly cloth, whether old towels or afghans or pet blankets, for their cats and dogs. I would think a veterinary hospital might too -- our vet usually has a sign up asking for donations of old towels.

I'm writing from Open Source, a public radio show based in Boston anddistributed around the country.

Two years ago, we started what's become a yearly tradition for us called Blogsday, http://www.radioopensource.org/blogsday-2007/ . Based loosely on Bloomsday, which celebrates "Ulysses" as an evocation of the world in a single day (in Joyce's case, June 16, 1904), the idea is to create a mosaic portrait of the blogosphere by reading excerpts of blog posts written all over the world on the same day, for one night, for one hour, on live radio. This year, we chose this past Tuesday, June 5, to collect posts from, and the show will air Thursday night from 7-8pm EST.

I'm writing because we loved this post, and it's on the shortlist to be included among our Blogsday Best of the June 5th Blogosphere collection. Congratulations!

On Thursday night, we'll bring in two accomplished and agile actors to read excerpts from our collection of posts on the air. I can't guarantee that your post will make it onto the show at this point (we're still knee-deep in our favorite posts), but you're a finalist.

We can't pay anything -- this is public radio after all -- but we can guarantee a respectful treatment, a national radio audience, and a link on our blog.

Let me know if you have any questions. I'll try to send another email if I can confirm that your post will definitely be on the show beforehand, but if things get too crazy I may just let you know after the fact.

Oh Mel, that's a horrible story. I am sorry you had to deal with such a terrible person. How could they have not known something was wrong for that long? So irresponsible.

In October I had to make the decision, for the first time, to put a beloved pet down. It is a hard thing to do. However I am certain you would have been so much nicer about giving the diagnosis then the vet I saw.

Mel,I'd like to say that when I have been faced with a decision, I have been grateful to my vet for letting me know that he thought it was time to let my pet go. It is a very hard decision to make, and a vet's professional opinion is invaluable in helping to make it.-Ruth Ellen